Ovarian Tumor

For 2 years, a 55-year-old woman's abdomen gradually enlarged; the pace of this growth had accelerated during the last 6 months. The patient, who had not seen a physician in 10 years, denied abdominal pain, nausea, vomiting, constipation, diarrhea, or any change in bowel habits. She had no shortness of breath or weakness. The patient reported no significant medical history, had no allergies, and took no medications. Her mother had died of ovarian cancer.

The patient was comfortable, alert and oriented, and in no acute distress. All extremities were emaciated. Her temperature was 36.9°C (98.4°F), and blood pressure was 132/87 mm Hg. Heart rate (89 beats per minute) and rhythm were regular, and S₁ and S₂ were audible; no sternal heave, apical beat, or murmurs were heard. The lungs were clear.

The abdomen was firm, nontender, distended, and obtunded (A and B). Bowel sounds were heard at the flanks bilaterally but not detected anteriorly. Caput medusae and jaundice were absent. The abdomen was dull to percussion throughout.

Laboratory studies revealed an elevated alkaline phosphatase level, 149 U/L; erythrocyte sedimentation rate, 51 mm/h; carcinoembryonic antigen (CEA) level, 21.7 µg/L; and CA-125 assay level, 71 U/mL (normal, lower than 35 U/mL). CT scanning of the chest, abdomen, and pelvis revealed a 45 × 36 × 28-cm, predominantly cystic mass with multiple loculations and 2 smaller solid components. The tumor arose from the pelvis and extended throughout the abdomen to the diaphragm and displaced the bowel and liver.

The patient was immediately referred to a gynecologic oncologist for diagnostic laparotomy; a total abdominal hysterectomy with bilateral oophorectomy was performed. The tumor and 44 lb of dark cystic fluid were removed from the abdomen; visual inspection of the tumor's interior demonstrated solid components (C). Pathologic examination of a specimen revealed a mucinous tumor of low malignant potential with focal intraepithelial carcinoma of the ovary. The ovarian stroma was clear, and all lymph nodes tested (para-aortic, right external iliac, right common iliac, and right obturator/hypogastric) were free of tumor.

The patient was discharged from the hospital in stable condition. Liver enzyme, CA-125 and CEA levels were evaluated every 3 months during the first postoperative year. Because the levels remained within normal limits, chemotherapy was not initiated.

Drs Brian L. Patterson, Martha Rumschlag, Douglas Budde, and Robert Karl of Providence Hospital and Medical Centers, Southfield, Mich, write that ovarian cancer is the leading gynecologic cancer and the fourth most common cause of cancer deaths among women.¹ The incidence is 12.9 to 15.1 cases per 100,000 women; about 25,000 new cases are diagnosed each year.² Risk factors for the disease include low parity, delayed childbearing, use of talc on the perineum, a high-fat diet, a family history of the disease, and carriage of the BRCA1 gene.

Half of epithelial carcinomas of the ovary are serous tumors, 25% are mucinous, and 15% are endometrioid; the remainder are clear cell, Brenner, mixed epithelial, and undifferentiated cancers. Fifty percent of these epithelial tumors, which compose 85% of ovarian neoplasms, are benign, 33% are frankly malignant, and 16% are of low malignant potential.³

Characteristically, epithelial tumors do not invade the ovarian stroma. Most commonly, benign epithelial growths-which are usually large, bilateral, and cystic-develop in women who are between the ages of 20 and 60 years. Most malignant epithelial tumors are seen in women who are older than 40 years; these carcinomas are solid, with areas of necrosis and hemorrhage.

When you suspect an ovarian tumor, obtain a CA-125 serum level. Between 80% and 85% of patients with epithelial ovarian cancer have a CA-125 level of more than 35 U/mL. One percent of unaffected women have a CA-125 level of over 35 U/mL; however, the assay's sensitivity is 97% and its specificity is 78% in postmenopausal women with an asymptomatic pelvic mass and a CA-125 level that exceeds 65 U/mL.³

Because ovarian tumors grow asymptomatically, the patient is unaware of a problem until an increase in her abdominal girth or other symptoms associated with an ovarian mass, such as intermittent abdominal pain or obstruction, occur. Diagnosis and staging, which is done mainly by laparotomy, often are not determined until the tumor progresses to a later stage. Usually, masses larger than 10 to 15 cm have spread into the abdomen and cause bowel or renal obstruction and cachexia secondary to carcinomatosis. Because of its intra-abdominal spread, this patient's ovarian cancer was classified as stage III; 5-year survival is 15% to 20% for persons in this group.³

This patient's laparotomy and pathology results indicated no metastasis, which had been suggested by the size of the tumor and the alkaline phosphatase and CEA values. These elevated levels most likely were secondary to the tumor-caused displacement of and pressure on the liver and bowel.

Postoperative treatment of patients who have stage III ovarian cancer with limited or no residual disease after surgery, consists of combination chemotherapy with cisplatin and paclitaxel. Approximately 70% of women respond to initial combination chemotherapy, and 40% to 50% have complete regression of disease.³ Patients who have advanced stage III or IV disease with residual tumor after surgery receive combination chemotherapy as well. The prognosis for these patients is poor; however, 5-year survival may reach as high as 15% with adjuvant therapy.

Screening for ovarian cancer consists mostly of bimanual examination during routine health maintenance or comprehensive examinations. If an ovarian mass or fullness in the pelvis is detected during a pelvic examination, transvaginal ultrasonography is indicated.

REFERENCES:1. Goroll AH, Mulley AG. Primary Care Medicine: Office Evaluation and Management of the Adult Patient. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2000.
2. Ferri FF. Ferri's Clinical Advisor. Instant Diagnosis and Treatment. 2002 ed. St Louis: Mosby; 2002.
3. Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. New York: McGraw-Hill; 1998.